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Percutaneous Radiologic Gastrostomy: a 12-Year Series

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Percutaneous Radiologic Gastrostomy: a 12-Year Series Gut and Liver, Vol. 4, Suppl. 1, September 2010, pp. S44-49 original article Percutaneous Radiologic Gastrostomy: A 12-Year Series Franco Perona, Giorgio Castellazzi, Alessandro De Iuliis, and Laura Rizzo Alliance Medical Italy, Lissone, Italy Background/Aims: Interventional radiologists have come the state of the art to achieve a feeding access in played a main role in the technical evolution of gas- patients with neoplastic involvement of the head and trostomy, from the first surgical/endoscopical ap- neck or oesophagus. However, PEG may fail in patients proaches to percutaneous interventional procedures. with stenotic lesions that cannot be passed by an This study evaluated the results obtained in a 12-year endoscope. Also, obesity, gastric surgery, or other ana- series. Methods: During the period December 1996 tomical abnormalities making transillumination of the ab- to December 2008, 254 new consecutive gastro- dominal wall difficult, may lead to failure of PEG stomies and 275 replacement procedures were per- procedures.1 formed in selected patients. All of the cases were treated by a T-fastener gastropexy and tube place- As reported in the Literature surgical gastrostomy ment. The procedures were assessed by analyzing in- would be necessary in these cases. Interventional dications, patient selection, duration of the procedures, Radiology as become a valid and effective therapeutic al- and mortality. Results: All 254 first gastrostomies ternative to many pathologic conditions and percutaneous were successful; replacement procedures were also radiological gastrostomy (PRG) represents an alternative successfully performed. One (0.2%) patient with se- that avoids both surgery and endoscopy.1 vere neurologic disorders died after the procedure Despite encouraging results in literature, this method without signs of procedure-related complications, and has not yet gained widespread clinical acceptance. The of- seven (1.3%) major complications occurred (four duo- fer of this promising technique to clinicians of depart- denal lesions with peritoneal leakage, two gastric ments for radiation oncology, head and neck surgery, neu- bleedings, and one gastric lesion). Minor complications rology has been enthusiastically taken and they have read- were easily managed; three tube ruptures were ily accepted the modality. resolved. Conclusions: This long-term series and fol- low-up showed that a group of interventional radiol- The reasons of this approach are related to the need of ogist can effectively provide gastrostomy placement parenteral nutrition or enteric route for nutrition, to and long-term tube management. Percutaneous gas- avoid secondary malnutrition. We have to take into ac- trostomy is less invasive than other approaches and it count that long-term nasogastric and parenteral devices satisfies the needs even of high-risk patients. (Gut are not feasible because of an increased risk of gas- Liver 2010;4(Suppl. 1):S44-49) tro-esophageal reflux and subsequent aspiration.2 Percutaneous gastrostomy represents a valid alternative, Key Words: Gastrostomy; Percutaneous endoscopic less invasive than surgical approach and more tolerated gastrostomy; T-fastener; Percutaneous radiological gas- from patients: it is an artificial entero-cutaneous fistula trostomy between stomach and the skin surface, and it can be ob- tained with endoscopic or radiologic method.3 INTRODUCTION In the last years, PEG has quickly replaced the surgical approach and it is the current standard procedure to ob- Percutaneous endoscopic gastrostomy (PEG) has be- tain a feeding access in these kind of patients.4 Correspondence to: Franco Perona Alliance Medical Italy, Piazza G. La Pira 9, Lissone (MI), Italy Tel: +39-039-46621, Fax: +39-039-4662201, E-mail: [email protected] DOI: 10.5009/gnl.2010.4.S1.S44 Perona F, et al: Percutaneous Radiologic Gastrostomy: A 12-Year Series S45 The reasons of failure of the endoscopic approach are spleen are marked by ultrasound. well known and allow the research of possible alter- The stomach was transorally probed with a 5 F catheter natives as percutaneous placement of feeding tubes like a and a guidewire, and then a nasogastric tube was placed valid option to surgery and endoscopy: the interventional shortly before the procedure to allow air insufflation: approach is easy and fast as well as less invasive as com- stomach was distended with variable volume of air from pared to surgery. 500 to 700 mL, using 60 mL syringe under fluoroscopic Few studies on PRG are focused on extensive series: control. Immediately before the catheter placement 5 mg so, the aim of this study is to analyze our experience in of Joshine N-butyl-bromide (Buscopan; Boehringer Ingel- PRG placement with gastropexy in large population focus- heim, Florence, Italy) was injected for gastroparesis in all ing on technical difficulties, patients selection and gastro- patients. After sterile cleaning of skin with Pyodine, in- stomy site management and complications. jection of Xylocane (2%) was obtained at the site of puncture.2 MATERIALS AND METHODS The area in which the gastrostomy tube will be in- serted is usually located in the left hypochondrium, 4-8 1. Patients cm from median line: a small skin incision is the first From January 1996 to December 2008, 529 patients step after local anaesthesia and then the stomach is punc- (229 women, 300 men; mean age, 65 years), referred to tured in mid-distal body, to avoid the gastric major arte- our Center, were considered eligible for PRG placement: rial branches, with 18-gauge needle. The regular place- 254 for first placement, and 275 for replacement. ment of the needle is detected by aspiration of air and The clinical indications for first procedure were neuro- flushing with contrast media; after checking the correct logical disease, head and neck cancers; we exclude from position of the needle the T-fastener anchor bar is loaded our study patients with total gastrectomy, gastric carcino- (Cope Gastrointestinal Suture Anchor; Cook, Blooming- matosis, extensive gastric varices, critical illness and se- ton, IN, USA) by pushing coaxially the guidewire. vere ascites. While, the indications for replacement were After that, the needle is removed and the first small tube malfunction or dislodgment or request of the refer- caliber introducer is inserted to secure the tract; the an- ring physician or patient.4,5 chor bar is then retracted and first suture between ante- Approval to the procedure was obtained from the hos- rior abdominal and stomach wall has been completed as pital ethics committee and informed consent obtained the T-fastener mechanism is fixed externally by suture; from all patients. one or two T-fasteners are usually placed nearby the site of proposed gastrostomy entry.1,3 2. Procedure introduction Serial dilatation of percutaneous gastric tract is done The protocol was identical for all the patients on first with Seldinger technique using dilators up to 12-14 F: fi- placement or replacement: before the procedure, complete nally, gastrostomy polyurethane (Wills Oglesby; Wilson anamnesis is obtained and a pertinent physical examina- Cook Inc., Bloomington, IN, USA) tube 12 F is placed, tion assured the appropriateness of gastrostomy (absence and fixed by means of a loop.3 of abdominal hernias, or cutaneous scars), and of gastro- The correct position is checked again by injecting con- stomy substitution. trast through the tube; the stomach is then decompressed All procedures have been monitored by analyzing in- for at least 12 hours following the procedure. T-fasteners dications, patients selection, duration of the procedures, will be removed within 5-10 days, under fluoroscopic and mortality. control. The presence of an anesthesiologist in the angiographic All patients have a 30-day post-procedure period of ob- room was required, and the vital parameters were servation by the same physician performing the proce- monitored. Technical success was accomplished when the dure.4 gastrostomy tube was effectively placed into the stomach, 4. Procedure for replacement and the correct function of the feeding tube was achieved.6 The same technique by insertion, under local anaes- thesia, of the guidewire through the tube and then the 3. Procedure for first placement placement of the optimal feeding tube in the matur tract. Patients usually were admitted to the hospital for at Two controls after the procedure and 24 hours later as- least 12 hours before the procedure. No sedation was sure the best standard of quality. used and no antibiotic were routinely given. The liver and S46 Gut and Liver, Vol. 4, Suppl. 1, September 2010 5. Major complications 4) Tube migration and the buried bumper syn- drome Major complication were defined as those who prolong- ing the hospital stay, requiring an additional procedure or The buried bumper syndrome is defined as migration of transfusion.1,2 the PEG tube into the gastric wall and the subsequent epithelization of the ulcer site. Buried bumper syndrome 1) Aspiration often manifests months to years after PEG placement Aspiration resulting in pneumonitis or pneumonia is (median duration was 35 months after PEG placement) as one of the most frequently reported major complications abdominal pain; difficulty feeding or flushing the tube; of PEG placement. Aspiration can occur either during or and inability to advance, withdraw, or rotate the tube. after the PEG placement procedure. Periprocedure aspira- Treatment involves removing the tube (which may require tion of
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